Lower Eyelid Blepharoplasty 23 Roger L

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Lower Eyelid Blepharoplasty 23 Roger L. Crumley, Behrooz A. Torkian, and Amir M. Karam

Anatomical Considerations the orbicularis oculi muscle and (2) an inner lamella, which includes tarsus and conjunctiva. The skin of the lower 2 In no other area of facial aesthetic surgery is such a fragile eyelid, which measures less than 1 mm in thickness, balance struck between form and function as that in eye- retains a smooth delicate texture until it extends beyond lid modification. Owing to the delicate nature of eyelid the lateral orbital rim, where it gradually becomes thicker structural composition and the vital role the eyelids serve and coarser. The eyelid skin, which is essentially devoid of in protecting the visual system, iatrogenic alterations in a subcutaneous fat layer, is interconnected to the under- eyelid anatomy must be made with care, precision, and lying musculus orbicularis oculi by fine connective tissue thoughtful consideration of existing soft tissue structures. attachments in the skin’s pretarsal and preseptal zones. A brief anatomical review is necessary to highlight some of these salient points. With the eyes in primary position, the lower lid should Musculature be well apposed to the globe, with its lid margin roughly The orbicularis oculi muscle can be divided into a darker tangent to the inferior limbus and the orientation of its re- and thicker orbital portion (voluntary) and a thinner and spective palpebral fissure slanted slightly obliquely upward lighter palpebral portion (voluntary and involuntary). The from medial to lateral (occidental norm). An inferior palpe- palpebral portion can be further subdivided into preseptal bral sulcus (lower eyelid crease) is usually identified ϳ5 to and pretarsal components (Fig. 23.2). The larger super- 6 mm from the ciliary margin and roughly delineates the ficial heads of the pretarsal orbicularis unite to form the inferior edge of the tarsal plate and the transition zone from medial canthal tendon, which inserts onto the anterior pretarsal to preseptal orbicularis oculi1 (Fig. 23.1). lacrimal crest, whereas the deep heads unite to insert at the posterior lacrimal crest. Laterally, the fibers condense Lamellae and become firmly attached at the orbital tubercle of 3 The eyelids have been considered as being composed of Whitnall, becoming the lateral canthal tendon. Although two lamellae: (1) an outer lamella, composed of skin and the preseptal orbicularis has fixed attachments with the medial and lateral canthal tendons, the orbital portion does not and instead inserts subcutaneously in the lateral orbital region (contributing to crow’s feet), overlies some of the elevator muscles of the upper lip and ala, and pos- sesses attachments to the infraorbital bony margin. Immediately beneath the submuscular fascia, extending along the posterior surface of the preseptal orbicularis, lies the orbital septum. Delineating the boundary between anterior eyelid (outer lamella) and intraorbital contents, it originates at the arcus marginalis along the orbital rim (continuous with orbital periosteum), and after fusing with the capsulopalpebral fascia posteriorly ϳ5 mm below the lower tarsal edge, it forms a single fascial layer that inserts near the tarsal base. The capsulopalpebral head of the inferior rectus is a dense, fibrous, connective tissue expansion, which by virtue of its ultimate attachments to the tarsal plate allows for lower lid retraction during downward gaze. During its forward extension, it encompasses the musculus obliquus inferior, and after reuniting anteriorly, it contributes to the formation of Lockwood’s suspensory ligament (inferior transverse liga- Fig. 23.1 Topographic anatomy of the eyelid, demonstrating natural ment, at which point it is termed the capsulopalpebral fascia, folds. (From Kohn R. Textbook of Ophthalmic Plastic and Reconstructive 4 Surgery. Philadelphia: Lea & Febiger; 1988. Reprinted by permission.) CPF). Although the majority of its fibers terminate near the 271 272 II Aesthetic Facial Surgery

Fig. 23.2 Major divisions of the m. orbicularis oculi into pretarsal, preseptal, and orbital components.

inferior tarsal border, some extend through orbital fat con- differences from its other counterparts, including a lighter tributing to compartmentalization, some penetrate the pre- color, a more fibrous and compact lobular pattern, and a septal orbicularis to insert subcutaneously about the lower frequent association with a sizable blood vessel near its eyelid crease, and others extend from the inferior fornix su- medial aspect. The orbital fat can be considered an ady- periorly to contribute to Tenon’s capsule (Fig. 23.3). namic structure because its volume is not related to body habitus, and once removed it is not thought to regenerate.

Orbital Fat Innervation Contained behind the orbital septum and within the orbital cavity, the orbital fat has been classically segmented Sensory innervation to the lower lid derives mainly from into discrete pockets (lateral, central, and medial), although the infraorbital nerve with minor contributions from the interconnections truly exist.5 The lateral fat pad is smaller infratrochlear and zygomaticofacial nerve branches. The and more superiorly situated, and the larger nasal pad is blood supply is obtained from the angular, infraorbital, divided by the inferior oblique muscle into a larger central and transverse facial arteries. Situated 2 mm below the fat compartment and an intermediate medial compartment. ciliary margin, between the orbicularis oculi and the tar- (During surgery, care must be taken to avoid injury to sus, is the marginal arcade, which should be avoided if a the inferior oblique.) The medial pad has characteristic subciliary incision is used.

Fig. 23.3 Cross-sectional diagram of the lower eyelid demonstrating connective tissue expansion of inferior rectus into its terminal insertions. 23 Lower Eyelid Blepharoplasty 273

Terminology tearing, a burning or gritty sensation, ocular discomfort, foreign bodies, mucus production, eyelid crusting, and Several descriptive terms are used pervasively in the lit- a frequent need to blink are all symptoms suggestive of erature of eyelid analysis and should be understood by borderline or inadequate tear production. A possible those involved in surgical management of this area. atopic cause has to be ruled out. Blepharochalasis is a commonly misused term. It is an Certain systemic diseases, particularly the collagen uncommon disorder of the upper eyelids, of unknown vascular diseases (i.e., systemic lupus erythematosus, cause, which affects mainly young and middle-aged scleroderma, periarteritis nodosa), Sjögren syndrome, females. Blepharochalasis is characterized by recurrent Wegener granulomatosis, ocular pemphigoid, and Stevens– attacks of painless unilateral or bilateral lid edema, caus- Johnson syndrome, can interfere with the glandular lubri- 6,7 ing a loss of skin elasticity and atrophic changes. cating function and should be identified. The infiltrative Dermatochalasis is an acquired condition of increased, ophthalmopathy of Graves’ disease can result in vertical abnormal laxity of the eyelid skin interrelated with eyelid retraction and inadequate corneal protection after genetic predisposition, natural aging phenomenon, and surgery and should be managed with medical treatment environmental influences. It is frequently associated with preoperatively and surgical conservatism during surgery. prolapsed orbital fat. Thyroid hypofunction associated with a myxedematous Steatoblepharon is a condition of true herniation or state may mimic the baggy eyelids of dermatochalasis pseudoherniation of orbital fat behind a weakened orbital and should be ruled out. Incomplete recovery of a previ- septum, causing areas of discrete or diffuse fullness in the ous facial nerve insult may interfere with eyelid closure eyelids. This condition and dermatochalasis are the two and predispose a patient to dry eye syndrome. most common reasons why a patient presents to discuss eyelid surgery. Festoons are single or multiple folds of orbicularis oculi Risk Factors for Postoperative Blindness in the lower lid that drape over onto themselves, creating an external, hammock-like bag. Depending on location, Postoperative blindness, the most catastrophic compli- this bag may be preseptal, orbital, or jugal (cheek). It may cation of blepharoplasty, is associated with retrobulbar 8,9 contain fat. hemorrhage. Factors that influence bleeding tenden- Malar bags are areas of soft tissue fullness on the lat- cies should therefore be identified and controlled before 10 eral edge of the infraorbital ridge and zygomatic promi- surgery. Ingestion of aspirin, nonsteroidal antiinflam- nence just superior to the palpebromalar sulcus. They matory drugs (NSAIDS), antiarthritics, cortisone prepa- are believed to be a result of recurrent dependent tissue rations, and vitamin E should be withheld for at least edema and secondary fibrosis. 14 days before surgery because of qualitative effects on platelet function. Over-the-counter medications should be discontinued as well because gingko biloba, for exam- Preoperative Evaluation ple, has been implicated in excessive bleeding. Similarly, St. John’s wort is known to have hypertensive effects A systematic and thorough preoperative assessment of through a monoamine oxidase inhibitor mechanism. blepharoplasty candidates is essential to minimize poten- Warfarin compounds, if medically feasible, should be tial postoperative complications. Thus, patient analysis is withheld to normalize the prothrombin time and may be directed to determining how much eyelid skin, orbicula- reinstituted 48 to 72 hours after surgery. ris oculi, and orbital fat needs to be resected to optimize Any history of abnormal or easy bruising, prolonged functional and aesthetic results, and whether the ocular clotting time, or family members with bleeding dyscrasia and adnexal structures will tolerate such a surgical manip- should be noted with appropriate coagulation profiles. ulation without undesirable sequelae. Hypertensive patients should be medically stabilized at least 2 weeks before surgery to ensure a nonfluctuating normotensive state. Women have a greater bleeding ten- Risk Factors for Postoperative dency during their menstrual period than at other cycle Dry Eye Syndrome times, and this should be considered in planning surgery. Other important factors include drinking and smoking Realizing that the protective physiological functions of history, as the former (in large amounts) may influence blinking and eyelid closure are temporarily impaired platelet function, and the latter has been associated with following blepharoplasty, an appropriate ocular history delayed wound healing and diminished flap viability. should elicit information that might put the patient at Finally, any patient with a documented or suspected his- greater risk for postoperative dry eye syndrome. Excessive tory of glaucoma must be evaluated and managed by an 274 II Aesthetic Facial Surgery

ophthalmologist to normalize intraocular pressures and Assessment of Fat Pockets guard against a potential acute closed-angle attack prior to any eyelid surgery. Some facial plastic surgeons rec- Evaluation of the adnexal structures should include ommend a routine ophthalmologic exam for all of their assessment of the fat pockets. Palpation of the infraor- patients preoperatively. bital rim is an essential component of this examination. A surgeon must recognize that a prominent rim limits the amount of orbital fat that can be removed without creating disparities in confluence between the lower eyelid and Ocular Assessment the anterior cheek. What appears to be an appropriate Examination of the eyes should begin with an over- fat resection may contribute to a sunken-eye appearance all inspection. The eyelid should be assessed for sym- if the patient has a very prominent rim. Assessment metry (by noting palpebral fissure height and length), of the fat pockets may be facilitated by directing the position of the lower eyelid margin with respect to patient’s gaze in certain directions; a superior gaze the inferior limbus, scleral show, and the presence of accentuates the medial and central pockets, whereas ectropion/entropion or exophthalmos/enophthalmos. looking upward and to the contralateral side accentuates Scars or skin lesions should be noted because it may be the lateral pocket. Further confirmation of fatty promi- possible to include these in the resection. Areas of skin nence may be obtained by gentle retropulsion of the discoloration or abnormal pigmentation should also be globe with the eyelid closed and observation of the noted. outward movements of the respective fat pads. Other baseline features of the periorbital area should be pointed out to the patient, particularly in lieu of the inabil- ity of blepharoplasty to correct them.11 The fine wrinkling Assessment of Lid-Supporting Structures and "crepe paper" appearance of the eyelid skin is not Because the most common cause of lower lid ectropion amenable to correction by blepharoplasty alone. Areas after blepharoplasty is failure to recognize a lax lower of abnormal pigmentation or discoloration (e.g., from lid before surgery, it is essential to properly assess the venous stasis) will not be changed if outside the area of lid-supporting structures. Two simple clinical tests aid in surgery and in fact may be more noticeable after surgery this evaluation. A lid distraction test (snap test)13 is per- (because of light-refractile changes associated with con- formed by gently grasping the midportion of the lower version of a convex surface to a concave or flattened one). eyelid between the thumb and index fingers and out- One of the greatest sources of dissatisfaction after lower wardly displacing the eyelid from the globe (Fig. 23.4). blepharoplasty is the persistence of malar bags. The patient Movement of the lid margin greater than 10 mm indicates should realize that the upward tension necessary to atten- an abnormally lax supporting lid structure and suggests uate such a soft tissue prominence would not be tolerated the need for a lid-shortening procedure. The lid retraction by the supporting structures of the lower lid and could test11 is used to assess lid tone as well as medial and lateral lead to ectropion. Finally, lateral smile lines (crow’s feet), despite the amount of lateral extension and undermining, are also not amenable to correction by standard blepharoplasty technique. All of these factors need to be discussed with the patient. As a minimum, baseline ocular assessment should document visual acuity (i.e., best corrected vision if glasses or contact lenses are worn), extraocular movements, gross visual fields by confrontation, corneal reflexes, the presence of Bell’s phenomenon and lagophthalmos. If there is any question of dry eye syndrome, the patient should be evaluated with Schirmer testing (to quantitate tear output) and tear film break-up times (to assess stability of precorneal tear film).12 Patients who demonstrate abnormalities in either or both of these tests or who have past or anatomical evidence that would predispose them to dry eye complications should be thoroughly evaluated by an ophthalmologist preoperatively. Also, a conservative Fig. 23.4 Lid distraction test used to assess laxity of tarsoligamentous skin–muscle excision (if not staged resection of upper and sling. (From Tenzel RR. Complications of blepharoplasty: orbital hema- lower lids) would seem prudent. toma, ectropion, and scleral show. Clin Plast Surg 1981;8:799.) 23 Lower Eyelid Blepharoplasty 275

there has been a surge of interest and a growth of proponents for this approach. The transconjunctival lower lid blepharoplasty respects the integrity of the orbicularis oculi, an active support structure of the lower eyelid. This minimizes the incidence of ectropion. Also, an external scar can be avoided. Proper patient selection for the transconjunctival approach is required. Ideal candidates include older patients with pseudoherniation of orbital fat and a limited amount of skin excess, young patients with familial heredi- tary pseudoherniation of orbital fat and no excess skin, all revision blepharoplasty patients, patients who do not want an external scar, patients with a history of keloids, and dark-skinned individuals who have a small possibility of hypopigmentation of the external scar.15,16 Because several authors have reported a significant reduction in short- and long-term complications with the transconjunctival approach to lower eyelid blepharoplasty compared with the skin–muscle method, the indications for the technique have been gradually expanding.15,17 The presence of excess lower lid skin does not preclude use of the transconjunctival approach. In the senior author’s practice, the most commonly performed lower lid procedure consists of transconjunctival fat excision, pinch excision of skin, and 35% trichloroacetic 15,18–20 Fig. 23.5 Lid retraction test used to assess lower eyelid tone and stabil- acid (TCA) peeling (described later). The skin exci- ity of medial and lateral canthal tendon attachments. (From Tenzel RR. sion is needed to recontour the lower eyelid once the fat Complications of blepharoplasty: orbital hematoma, ectropion, and has been removed. There frequently is less excess than one scleral show. Clin Plast Surg 1981;8:800.) initially estimates before the fat excision is performed.17,21 canthal tendon stability (Fig. 23.5). By using the index finger to inferiorly displace the lower lid toward the orbital Preparation rim, observations are made in terms of punctal or lateral While sitting upright, the patient is asked to look upward. canthal malposition (movement of puncta greater than This helps to refresh the surgeon’s memory as to which fat 3 mm from the medial canthus indicates an abnormally pads are the most prominent, and these are marked. The lax canthal tendon and suggests the need for tendoplica- patient is then placed supine. Two drops of ophthalmic tion). Releasing the eyelid, the pattern and rate of return tetracaine hydrochloride 0.5% are then instilled into each of the lid to resting position should be observed. A slow inferior fornix. Prior to the local injections, our patients return, or one that requires multiple blinks, indicates poor typically receive some intravenous sedation composed lid tone and eyelid support. Again, a conservative skin– of midazolam (Versed) and meperidine hydrochloride muscle resection and lower lid–shortening procedure (Demerol). Ten milligrams of intravenous dexametha- would be warranted. sone (Decadron) is also given to help minimize postoperative edema. A local anesthetic mixture, consisting of equal parts of 0.25% bupivacaine (Marcaine) and Surgical Technique 1% lidocaine (Xylocaine) with 1:100,000 epinephrine to which is added a 1:10 dilution of sodium bicarbonate, Three basic surgical approaches have been described in is then injected into the lower lid conjunctiva using a lower lid blepharoplasty: (1) transconjunctival, (2) skin– 30 gauge needle. Experience has demonstrated that this muscle flap, and (3) skin flap. mixture affords prolonged analgesic effect while minimizing the sting of initial infiltration through alkalinization Transconjunctival Approach of the local agent. The needle is advanced through the conjunctiva until the bony orbital rim is palpated. The local The transconjunctival approach to lower eyelid blepha- is slowly injected as the needle is withdrawn. This is per- roplasty was first described in 1924 by Bourquet.14 formed medially, centrally, and laterally. Several surgeons Although it is not a new procedure, over the past 10 years also like to inject transcutaneously, although we have 276 II Aesthetic Facial Surgery

The upper lid is placed over the globe to protect it. Either a guarded needle-tip bovie on a low setting or a no. 15 blade is used (others prefer a laser) to make the transconjunctival incision 2 mm below the inferior edge of the inferior tarsal plate. This inferior tarsal edge appears gray through the conjunctiva. The medial aspect of the incision is in line with the inferior punctum. The incision is carried just 4 to 5 mm shy of the lateral canthus. Immediately after the transconjunctival incision is made, a single 5–0 nylon suture is placed in the conjunctiva closest to the fornix and used to retract the posterior lamella over the entire cornea (Fig. 23.8). Mosquitos Q1 snapped onto the patient’s headwrap are used to hold the sutures under tension. The conjunctiva acts as a natural corneal protector and the superior retraction allows for easier plane dissection. The two skin hooks are then carefully removed and a Desmarres retractor is now used to evert the free edge of the lower lid (Fig. 23.9). The distance of the transconjunctival incision from the inferior edge of the inferior tarsal plate determines whether one will approach the orbital fat preseptally or postseptally.16 We usually utilize the preseptal approach; Fig. 23.6 Transconjunctival approach to lower eyelid fat pockets. therefore, our incisions are always ϳ2 mm below the tarsus. Simultaneous eversion of the lower eyelid and ballottement of the globe produces a bulge of orbital fat that helps to guide the dissec- The preseptal plane is an avascular plane between the 22 tion. (From Baylis HI, Long JA, Groth MJ. Transconjunctival lower orbicularis oculi and the orbital septum. Because the orbital eyelid blepharoplasty: technique and complications. Ophthalmology septum is still intact while the preseptal plane is being 1989;96:1027.) developed, orbital fat does not bulge into one’s view. The visualization obtained is closely similar to the orientation found that this is usually not necessary and may lead to one is used to having when performing a skin–muscle unnecessary bruising.

Incision After waiting a full 10 minutes for vasoconstriction to occur, the lower lid is gently retracted by an assistant using two small, double-pronged skin hooks (Figs. 23.6 and 23.7).

Fig. 23.7 The needle-tip bovie is poised to initiate the incision. (A corneal protector, or upper lid skin, is used for protection when the actual incision Fig. 23.8 Retraction suture in place; cotton-tipped applicator spreads is made.) incision site. 23 Lower Eyelid Blepharoplasty 277

from the direct approach is one to which most facial plastic surgeons are less accustomed. After the 5–0 suture retraction and Desmarres retractor are in place, the preseptal plane is developed with a com- bination of blunt dissection with a cotton swab and sharp dissection with scissors. It is mandatory to maintain a dry surgical field. Therefore, a bipolar cautery, “hot loop,” or monopolar cautery is used to cauterize any bleeders. The medial, central, and lateral fat pads are each indi- vidually identified through the septum with the help of some gentle digital pressure on the conjunctiva covering the globe. The orbital septum is then opened with scissors. Using forceps and a cotton-tipped applicator, the excess fat is carefully teased above the orbital rim and septum. Care must be taken to remove only the excessive and herniated fat because the eyes may take on a hollowed-out appearance following excessive fat excision. The ultimate goal is to achieve a lower eyelid contour that forms a smooth, gentle concave transition between it and cheek skin. A 30 gauge needle is then used to inject a small amount of local anesthetic into the excess fat (Fig. 23.11). The bipo- Fig. 23.9 Desmarres retractor exposes orbital septum. lar cautery is used to cauterize across the fat stalk. When one is sure the entire stalk has been cauterized, scissors are flap blepharoplasty. The orbital septum will still have to used to cut across the cauterized area. Others, notably Cook, be opened to access the orbital fat below (Fig. 23.10). reduce fat volume with electrocautery, minimizing surgi- Others prefer the postseptal approach to the orbital cal excision. Many surgeons feel that the lateral fat pocket fat.19 To directly access the fat pads the conjunctiva is should be explored initially because its volume contribution incised ϳ4 mm below the inferior border of the inferior becomes more difficult to assess after removal of its adja- tarsal plate and directly toward the anterior edge of the cent and interconnected central fat pad.11,23 After excess inferior orbital rim. The big advantage of this method is that fat has been removed from each compartment, the field is the orbital septum is kept completely intact. Proponents examined to make sure there is no bleeding. Although CO2 for this technique state that the intact orbital septum laser fat excision has been advocated based on the advan- adds to the support of the lower eyelid. One disadvantage tages of hemostatic efficiency, precision, and reduced tissue is that the orbital fat immediately bulges into one's view. trauma, the increased costs, requirements for highly trained Care must be taken not to incise close to the conjunctival personnel, and additional laser precautions have led us and cul-de-sac to avoid the risk of synechiae.16 Also, the view others to abandon laser incisions for lower lid surgery.24,25

Fig. 23.10 Fat appearing through orbital septum. Fig. 23.11 Fat of medial compartment, partially excised. 278 II Aesthetic Facial Surgery

The Desmarres retractor should be removed peri- odically and the lower eyelid redraped over the fat that remains in place to facilitate examination of the contour of the eyelid. The fat that is removed is retained on a gauze on the surgical field in order from lateral to medial, allowing for comparison with the fat removed from the opposite side. For example, if preoperatively the surgeon felt that the right lateral fat pad was much larger than all others, then intraoperatively that compartment would have the most fat removed. The medial and central fat compartments are sepa- rated by the inferior oblique muscle. This muscle must be clearly identified prior to the excision of excess fat from these compartments to prevent muscle injury. The medial fat pad is whiter than the central and lateral fat pads. This helps in its identification. The lateral compart- Fig. 23.13 Pinch excision progression. ment is usually isolated from the central one by a fascial band off the inferior oblique muscle. This fascial band can with care taken not to cut the lower eyelashes (Fig. 23.13). be cut safely. The edges of the skin pinch are then brought together with After each successive fat compartment is treated, the interrupted 6–0 fast-absorbing gut stitches. Several authors entire field must again be examined for bleeding. After have closed this incision with cyanoacrylate (Histoacryl) or all of the bleeding has been cauterized with the bipolar, fibrin glue.15,26 the Desmarres and the retraction sutures are removed. Patients with crepey or fine lower eyelid rhytids are The lower lid is gently elevated upward and outward and then treated with a 25 to 35% TCA peel. The TCA is applied then allowed to snap back into its proper position. This immediately below the skin pinch incision. A typical “frost” allows for proper realignment of the edges of the trans- is generated (Fig. 23.14). Phenol is not used for lower conjunctival incision. No suture is required, although lids in our hands because the erythema and inflammation some surgeons feel more comfortable closing the incision phase is much longer than the TCA peel. with one, buried 6–0 fast-absorbing gut stitch. Both eyes should then be irrigated with sodium chloride (ophthalmic Bbalanced salt solution). Postoperative Care In an older patient with skin excess, a lower lid skin Immediately after surgery, the patient is kept quiet with pinch or chemical peel may now be performed. Using fixa- head elevated at least 45 degrees. Cold compresses are tion forceps or Brown–Adson forceps, a 2 to 3 mm raised placed on both eyes and changed every 20 minutes. The fold of redundant skin is raised just below the ciliary margin (Fig. 23.12). The skin fold is excised with sharp scissors,

Fig. 23.14 Thirty percent trichloroacetic acid (TCA) lower lid peel frost. (Different patient in whom no pinch excision was done.) When Fig. 23.12 Fixation forceps used to create ridge or mound for pinch the pinch technique is used, the TCA must not be applied any closer excision. than 1 mm below the suture line. 23 Lower Eyelid Blepharoplasty 279 patient is observed closely for at least an hour for any prepping and sterile draping, the incision line (beginning signs of bleeding complications. The patient is given strict laterally) and entire lower lid down to the infraorbital instructions to limit physical activity for the next week. rim are infiltrated (superficial to orbital septum) with our The patient who is diligent about the cold compresses anesthetic mixture previously described. and head elevation during the first 48 hours will experience substantially less swelling. Some physicians place Incision their patients on sulfacetamide ophthalmic drops during the first 5 postoperative days to help prevent an infection The incision, which is begun medially with a no. 15 scalpel while the transconjunctival incision is healing. blade, is only through skin to the level of the lateral canthus, but through skin and musculus orbicularis oculi lateral to this point. Using a blunt-tipped, straight-dissection scissors, Skin–Muscle Flap Approach the incision is undermined in a submuscular plane from lateral to medial and is then cut sharply by orientation of The skin–muscle flap approach was perhaps the most the blades in a caudal direction (optimizing the integrity of commonly used method in the 1970s and early 1980s. In the pretarsal muscle sling). A Frost-type retention suture, patients with a large amount of excess skin and orbicula- using 5–0 nylon, is then placed through the tissue edge above ris oculi as well as fat pseudoherniation, this is an excellent the incision to aid in counterretraction. Using blunt dissec- procedure. The advantages of this approach are related to tion (with scissors and cotton-tipped applicators), a skin– the safety and facility of dissecting in the relatively avas- muscle flap is developed down to, but not below, the cular submuscular plane and the ability to remove redun- infraorbital rim to avoid disruption of important lymphatic dant lower eyelid skin. One must realize that even with channels.27 Any bleeding points up to this point should the skin–muscle flap one is limited by how much skin be meticulously controlled with the handheld cautery or can safely be removed without risking scleral show and bipolar cautery,28 with conservatism exercised in the even an ectropion. Persistent rhytids often remain despite superior margin of the incision to avert potential thermal attempts to safely resect redundant eyelid skin. trauma to the eyelash follicles.

Preparation Fat Removal Preparation for this method is similar to that for the If preoperative assessment suggests the need for fat-pad transconjunctival approach, except that tetracaine drops management, selective openings are made through the are not necessary. A subciliary incision is planned 2 to orbital septum over the areas of pseudoherniation and 3 mm beneath the eyelid margin and is marked with a are guided by gentle digital pressure of the closed eyelid marking pen or methylene blue with the patient in the against the globe. Although alternatives aimed at electro- sitting position. Any prominent fat pads are also marked. cauterizing a weakened orbital septum exist29 that may The importance of marking the patient in the upright obviate violation of this important barrier, we are comfort- position before injection relates to the changes in soft able with the long-term results and predictability of our tissue relationships that occur as a result of dependency technique of direct fat-pocket management. and infiltration. The medial extent of the incision is marked After opening the septum (usually 5 to 6 mm above the 1 mm lateral to the inferior punctum to avoid potential orbital rim), the fat lobules are gently teased above the damage to the inferior canaliculus, whereas the subcili- orbital rim and septum using forceps and a cotton-tipped ary extension is carried to a point ϳ8 to 10 mm lateral applicator. The fat resection technique is very much as to the lateral canthus (to minimize potential for round- described in the transconjunctival technique and is not ing of the canthal angle and lateral scleral show). At this repeated. point, the lateral-most portion of the incision achieves a Access to the medial compartment may be limited in more horizontal orientation and is planned to lie within part by the medial aspect of the subciliary incision. This a crow’s-foot crease line. Care should be exercised in incision should not be extended; instead, the fat should planning the lateral extension of this incision to allow at be gently teased into the incision, taking care to avoid least 5 mm, and preferably 10 mm, between it and the the inferior oblique muscle. The medial fat pad is distin- lateral extension of the upper blepharoplasty incision to guished from the central pad by its lighter color. obviate prolonged lymphedema. Our patients typically receive intravenous sedation Closure composed of midazolam and meperidine hydrochloride after the preoperative marking has been accomplished In preparation for skin excision and closure the patient and intravenous dexamethasone is in. Before surgical is asked to open the jaw widely and gaze in a superior 280 II Aesthetic Facial Surgery

direction. This maneuver creates a maximal voluntary and eyelid induration), an increased risk of vertical eyelid separation of the wound edges and assists the surgeon retraction, and a higher demand placed on preoperative in performing accurate resection of the skin–muscle flap. assessment of the fat pockets because of obscured sub- With the patient maintaining this position, the inferior septal observation by the overlying orbicularis oculi.31,32 flap is redraped over the subciliary incision in a super- The initial incision through skin is made only through otemporal direction. At the level of the lateral canthus, the lateral extension of the subciliary marking to facili- the extent of skin muscle overlap is marked and incised tate undermining. With an assistant maintaining down- vertically. A tacking stitch of 5–0 fast absorbing gut is ward traction on the lower eyelid skin (by placing a hand then placed to maintain the position of the flap. Using near the orbital rim), the lateral skin edge is grasped and straight scissors, the areas of overlap are conservatively pulled superiorly while sharp-scissors dissection carefully resected (medial and lateral to the retention suture) undermines the skin flap to a point just below the orbital so that edge-to-edge apposition can be maintained with- rim. With the undermining accomplished, the subciliary out the need for reinforcement. It is important to bevel incision is completed with the scissors. All bleeding points the blades caudally to allow for a 1 to 2 mm strip resec- are precisely cauterized. tion of orbicularis oculi on the lower flap edge to avoid If the problem is skin redundancy or excessive wrin- a prominent ridge at the time of closure. Some sur- kling only, the skin flap is simply redraped in the manner geons refrigerate the resected skin (viable for at least described for skin–muscle flap. If access to the orbital fat 48 hours) in sterile saline in case replacement tissue compartments is required, these are approached by incis- graft is needed after an overzealous resection eventuat- ing the orbicularis oculi ϳ3 to 4 mm inferior to the initial ing in ectropion. It is far better to prevent such compli- skin incision or via the transconjunctival approach. How- cations by performing a conservative resection. ever, when orbicularis hypertrophy or festooning is pres- After fat removal from the second eyelid, simple inter- ent, optimal management is achieved by development of rupted 6–0 fast-absorbing gut sutures are placed to close independent skin and muscle flaps. In this case, the muscle the incision on the initial eyelid. Attention can then be is incised (beveling caudally) across the extent of the inci- redirected back to redraping, trimming, and suturing the sec- sion, beginning ϳ2 mm below the skin incision to preserve ond eyelid. Finally, inch-long sterile strips are placed to aid the pretarsal muscle sling. Undermining of the muscle flap in temporal support, and a light application of antibiotic is carried to just below the most dependent muscle roll ointment is applied to the sutured incision after irrigating (with festooning) or to a point that will allow effacement the eyes with sodium chloride (balanced salt solution). of a prominent muscle bulge (with hypertrophy) after muscle resection. After fat-pad management, the muscle flap is reinforced by suturing of its lateral end to orbital Postoperative Care periosteum with 5–0 Vicryl (Ethicon, Inc., Somerville, NJ) and reapproximation of its pretarsal muscle edges with a Postoperative care after the skin–muscle approach is few interrupted 5–0 chromic sutures. Again, skin closure essentially identical to the aftercare used in the transcon- follows the pattern previously described. junctival approach. Bacitracin ophthalmic ointment is given to the patient for the subciliary incision. Iced saline compresses, head elevation, and limited activity are stressed to all patients. Complications

Complications after blepharoplasty are usually the result of Skin Flap Approach overzealous skin or fat resection, lack of hemostasis, or an inadequate preoperative assessment.33,34 Less commonly, The skin flap approach is perhaps the oldest and the least an individual’s physiological response to wound repair frequently used. This method allows independent resection may lead to undesirable sequelae despite execution of the and redraping of lower eyelid skin and underlying orbicu- proper technique. The goal in minimizing complications laris oculi and is effective in repositioning and redraping consequent to blepharoplasty must therefore focus on pre- excessively wrinkled, redundant, or deeply creased skin.30 vention by identifying and managing known risk factors. In cases involving hypertrophy or festooning of the orbicularis oculi, direct access is provided for management, which allows for a greater and safer resection than would Ectropion otherwise be tolerated if the flap were raised as a conjoined musculocutaneous unit. Disadvantages of this approach One of the most common complications after lower lid include a more tedious dissection that is associated with blepharoplasty is eyelid malposition, which may range greater skin trauma (manifested by increased bleeding in presentation from a mild scleral show or rounding of 23 Lower Eyelid Blepharoplasty 281 the lateral canthal angle, to a frank ectropion with actual aspiration or by creating a small stab wound over it with a eyelid eversion. In most cases resulting in permanent no. 11 blade. Hematomas that are large and present early, ectropion, a failure to address excessive lower lid lax- that are expanding, or that represent symptomatic retro- ity is the etiologic culprit. Other causes include exces- bulbar extension (decrease in visual acuity, proptosis, ocu- sive skin or skin–muscle excisions, inferior contracture lar pain, ophthalmoplegia, progressive chemosis) demand along the plane of the lower lid retractors and orbital sep- immediate exploration and hemostatic control. In the tum (greater in skin flap technique), inflammation of the case of the latter, urgent ophthalmologic consultation and fat pockets, and, rarely, destabilization of the lower lid orbital decompression are the mainstays of treatment. retractors (a potential yet uncommon complication of the transconjunctival approach). Temporary ectropion has been associated with lid loading from reactionary edema Blindness or hematoma and muscle hypotonicity. Blindness, though rare, is the most feared potential com- A conservative approach to management may include plication of blepharoplasty. It occurs with an incidence of the following: (1) a short course of perioperative ste- ϳ0.04%,35 typically presents itself within the first 24 hours roids with cold compresses and head elevation to man- after surgery, and is associated with orbital fat removal and age edema; (2) warm and cool compresses alternated to the development of a retrobulbar hematoma (medial fat hasten resolution of minor established hematomas and pocket most commonly involved). Commonly implicated improve circulatory status; (3) repeated squinting exer- causes of retrobulbar hemorrhage include the following: cises to improve muscle tonus; (4) gentle massage in an (1) excessive traction on orbital fat resulting in disruption upward direction; and (5) supportive taping of the lower of small arterioles or venules in the posterior orbit; (2) lid (upward and outward) to assist in corneal protection retraction of an open vessel beneath the septum after fat and tear collection. release; (3) failure to recognize an open vessel because of When skin excisions are recognized to be excessive vasospasm or epinephrine effect; (4) direct vessel trauma within the first 48 hours, the banked eyelid skin should resulting from injections done blindly beneath the orbital be used as a replacement graft. If recognition is delayed, septum; and (5) rebleeding after closure resulting from any conservative measures to protect the eye should be used maneuver or event that leads to an increased ophthalmic to allow the scar to mature and a full-thickness graft (pref- arteriovenous pressure head. erably upper eyelid skin or, alternatively, postauricular Early recognition of a developing orbital hematoma can skin, or foreskin in males) used to replace the deficit. In be facilitated by delaying intraoperative closure (first side), many cases, a lid-shortening procedure is combined with avoiding occlusive-pressure eye dressings, and extending the tissue grafting and is the mainstay of treatment when the postoperative observational period. Although many an atonic lid is present. Management of persistent indura- methods of management have been described to manage tions, resulting from hematoma formation or inflamma- threatened vision resulting from elevated intraocular pres- tory responses of the fat pockets, generally involves direct sures (reopening the wound, lateral canthotomy, steroids, depot injections of corticosteroid. diuretics, anterior chamber paracentesis), the most effective definitive treatment is immediate orbital decompres- Hematomas sion, which is usually accomplished through medial wall and orbital floor resections.8,36 Certainly, ophthalmologic Collections of blood beneath the skin surface can usually consultation is advisable. be minimized before surgery by optimizing coagulation profiles and normotensive status during surgery through delicate tissue handling and meticulous hemostasis and Epiphora after surgery through head elevation, cold compressing, a controlled level of activity, and appropriate analgesic sup- Assuming dry eye syndrome was ruled out before surgery port. Should a hematoma develop, its extent and time of or managed appropriately intraoperatively (conservative presentation will guide management. and staged resections), a dysfunctional lacrimal collect- Small, superficial hematomas are relatively common ing system rather than a high glandular output state is and are typically self-limiting. If organization occurs with typically responsible for postoperative epiphora (although the development of an indurated mass and resolution is reflex hypersection may be a contributing factor because slow or nonprogressive, conservative steroid injections of coexistent lagophthalmos or vertical retraction of may be used to hasten the healing process. Moderate or the lower lid). This response is common in the early postop- large hematomas recognized after several days are best erative period and is usually self-limited. Causes include the managed by allowing the clot to liquify (7 to 10 days) and following: (1) punctal eversion and canalicular distortion then evacuating the hematoma through large-bore needle secondary to wound retraction and edema; (2) impairment 282 II Aesthetic Facial Surgery

of the lacrimal pump resulting from atony, edema, Wound dehiscence may develop as a result of closure hematoma, or partial resection of the orbicularis oculi sling; under excessive tension, early removal of sutures, exten- and (3) a temporary ectropion resulting from lid loading. sion of an infectious process (unusual), or hematoma Outflow obstructions, secondary to a lacerated inferior (more commonly). Skin separation is seen most often in canaliculus, are preventable by keeping the lower lid inci- the lateral aspect of the incision with the skin–muscle and sion lateral to the punctum. Should laceration injury occur, skin techniques, and treatment is directed to supportive primary repair over a Silastic stent (Crawford tube; Dow taping or resuturing. If tension is too great for conservative Corning, Midland, MI) is recommended. Persistent punctal management, then a lid suspension technique and lateral eversion can be managed by cauterization or diamond exci- grafting should be considered. Skin slough may develop sion of the conjunctival surface below the canaliculus. as a result of devascularization of the skin segment. It is almost exclusively seen in the skin-only technique and typically occurs in the lateral portion of the lower eyelid Suture Line Complications after wide undermining and subsequent hematoma formation. Treatment consists of local wound care, evacuation of Milia or inclusion cysts are common lesions seen along any hematomas, establishment of a line of demarcation, the incisional line resulting from trapped epithelial debris and early skin replacement to obviate scar contracture of beneath a healed skin surface or possibly from the occlu- the lower lid. sion of a glandular duct. They are typically associated with simple or running cuticular stitches. Their formation is minimized by subcuticular closure. If they develop, defini- Skin Discoloration tive therapy is aimed at uncapping the cyst (no. 11 blade or epilation needle) and teasing out the sac. Granulomas Areas of skin undermining are frequently evident as may develop as nodular thickenings within or beneath hyperpigmentation in the early recovery period secondary the suture line and are typically treated by steroid injec- to bleeding beneath the skin surface with subsequent tions if small and by direct excision if large. Suture tunnels hemosiderin formation. This process is usually self-limiting develop as a result of prolonged suture retention and epi- and often takes longer to resolve in darkly pigmented thelial surface migration along the suture tract. Preventive individuals. It is imperative during the healing process, and treatment includes early suture removal (3 to 5 days), and particularly in this patient population, to avoid direct sun- definitive treatment involves unroofing the tunnel. Suture light because this may lead to permanent pigment changes. marks are also related to prolonged suture retention and Refractory cases (after 6 to 8 weeks) may be considered for their formation can usually be avoided by using a rapidly camouflage, periorbital peeling, or depigmentation therapy absorbing suture (fast-absorbing gut or mild chromic), by (e.g., hydroxyquinone, kojic acid). Telangiectasias may removing a monofilament suture early, or by employing a develop after skin undermining, particularly in areas subcuticular closure. beneath or near the incision, and most commonly occur in patients with preexisting telangiectasias. Treatment options may include chemical peeling or dye laser ablation. Wound Healing Complications Although rare, hypertrophic or prominent lower eyelid Ocular Injury scars may develop because of improper placement of the lower lid incision. If extended too far medially in the Corneal abrasions or ulcerations may result from inadvert- epicanthal region, bow-string or web formation may ent rubbing of the corneal surface with a gauze sponge or occur (conditions usually amenable to correction by cotton applicator, instrument or suture mishandling, Z-plasty technique). A lateral canthal extension (which or desiccation developing as a result of lagophthalmos, normally overlies a bony prominence) that is oriented ectropion, or preexistent dry eye syndrome. Symptoms too obliquely downward or is closed under excessive suggestive of corneal injury, which include pain, eye tension predisposes an incision to hypertrophic scarring, irritation, and blurred vision, should be confirmed by fluo- and during healing the vertical contraction vectors act on rescein staining and slitlamp examination by an ophthal- the lateral lid to favor scleral show or eversion. If the lower mologist. Therapy for mechanical injury typically involves lid incision is oriented too far superiorly or too close to use of an antibiotic ophthalmic drop with lid closure the lateral aspect of the upper lid incision, the forces of until epithelialization is complete (usually 24 to 48 hours). contraction (now favoring a downward pull) provide Treatment for dry eye syndrome includes the addition of conditions that predispose the patient to lateral canthal ocular lubricants, such as Liquitears and Lacri-lube. hooding. Again, proper treatment should be aimed at Extraocular muscle imbalance, manifested by gaze reorienting the direction of contracting vectors. diplopia, may be seen and is often transitory, presumably 23 Lower Eyelid Blepharoplasty 283 reflecting resolution of an edematous process. However, 8. Sacks SH, Lawson W, Edelstein D, et al. Surgical treatment of blindness permanent muscle injury may result from blind clamping, secondary to intraorbital hemorrhage. Arch Otolaryngol Head Neck Surg 1988;114:801 deep penetration of the fat pockets during sectioning of 9. Mahaffey PJ, Wallace AF. Blindness following cosmetic blepharoplasty: the pedicle, thermal injury resulting from electrocauteri- a review. Br J Plast Surg 1986;39:213 zation, suture incorporation during closure, or ischemic 10. Callahan MA. Prevention of blindness after blepharoplasty. Ophthal- contracture of the Volkman type. Patients with evidence mology 1983;90:1047–1051 11. Beekhuis GJ. Blepharoplasty. Otolaryngol Clin North Am 1982;15: of refractory and incomplete recovery of muscle function 179 should be referred to an ophthalmologist for evaluation 12. McKinney P, Zukowski ML. The value of tear film breakup and schirm- and definitive treatment. er’s tests in preoperative blepharoplasty evaluation. Plast Reconstr Surg 1989;84:572 13. Holt JE, Holt GR. Blepharoplasty: indications and preoperative assessment. Arch Otolaryngol 1985;111:394 Contour Irregularities 14. Bourquet J. Les hernies graisseuses de l’orbite: notre traitment chirur- gical. Bull Acad Natl Med 1924;92:1270–1272 Contour irregularities are generally caused by technical 15. Perkins SW, Dyer WD II, Simo F. Transconjunctival approach to lower omissions. Overzealous fat resection, particularly in a eyelid blepharoplasty. Arch Otolaryngol Head Neck Surg 1994;120: patient with a prominent infraorbital rim, results in 172–177 16. Mahe E. Lower lid blepharoplasty: the transconjunctival approach: a lower lid concavity and contributes to a sunken-eye extended indications. Aesthetic Plast Surg 1998;22:1–8 appearance. Failure to remove enough fat (common in 17. Zarem HA, Resnick JI. Minimizing deformity in lower blepharopasty: lateral pocket) leads to surface irregularities and persist- the transconjuctival approach. Plast Reconstr Surg 1991;88:215 ent bulges. A ridge that persists beneath the incision line 18. McKinney P, Zukowshi ML, Mossie R. The 4th option: a novel approach to lower lid blepharoplasty. Aesthetic Plast Surg 1991;15: is usually the result of inadequate resection of a strip of 293–296 orbicularis oculi before redraping. Areas of induration 19. Baylis HI, Long JA, Groth MJ. Transconjunctival lower eyelid blepharo- or lumpiness below the suture line usually can be plasty. Ophthalmology 1989;96:1027 attributed to unresolved or organized hematoma, tissue 20. Cheney ML. Facial Surgery: Plastic and Reconstructive. Baltimore: Williams & Wilkins; 1987:895–904 reaction or fibrosis secondary to electrocauterization or 21. Netscher DT, Patrinely JR, Peltier M, et al. Transconjunctival versus thermal injury, or soft tissue response to fat necrosis. transcutaneous lower eyelid blepharoplasty: a prospective study. Plast Treatment in each case is directed at the specific cause. Reconstr Surg 1995;96:1053–1059 Persistent fat bulges are managed by resection, whereas 22. Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1973;1:3–8 areas of lid depression can be managed by sliding fat- 23. Spira M. Blepharoplasty. Clin Plast Surg 1978;5:121 pad grafts, free-fat or dermal fat grafts,37 or orbicularis 24. David LM. The laser approach to blepharoplasty. J Dermatol Surg oculi flap repositioning. Some patients with such bulges Oncol 1988;14:741 or prominences respond to direct injections of triamci- 25. Mele JA III, Kulick MI, Lee D. Laser blepharoplasty: is it safe? Aesthetic Plast Surg 1998;22:9–11 3 noline (40 mg/cm ). In selected cases, infraorbital rim 26. Mommaerts MY, Beirne JC, Jacobs WI, Abeloos JSV. Use of fibrin glue in reductions distract noticeability from a hollow-eye lower blepharoplasties. J Craniomaxillofac Surg 1996;24:78–82 appearance and may be used as an adjunctive technique. 27. Holt JE, Holt GR, Cortez EA. Blepharoplasty. Ear Nose Throat J 1981;60:42 Unresolved hematomas and areas of heightened inflam- 28. Robinson L, Crumley RL. Electrocoagulation in blepharoplasty: experi- Q2 matory response may be managed with conservative mental data in the rabbit, 1990; unpublished. injections of steroids. 29. Cook TA, Dereberry J, Harrah ER. Reconsideration of fat pad management in lower lid blepharoplasty surgery. Arch Otolaryngol 1984;110:521 References 30. Klatsky SA, Manson PN. Separate skin and muscle flaps in lower lid 1. Zide BM. Anatomy of the eyelids. Clin Plast Surg 1981;8:623 blepharoplasty. Plast Reconstr Surg 1981;67:151 2. Aguilar GL, Nelson C. Eyelid and anterior orbital anatomy. In: Hornblass 31. Wolfey DE. Blepharoplasty: the ophthalmologist’s view. Otolaryngol A, ed. Oculoplastic, Orbital and Reconstructive Surgery. Vol. 1: Eyelids. Clin North Am 1980;13:237 Baltimore: Williams & Wilkins; 1988 32. McCollough EG, English JL. Blepharoplasty: avoiding plastic eyelids. 3. Jones LT. New concepts of orbital anatomy. In: Tessier P, Callahan A, Arch Otolaryngol Head Neck Surg 1988;114:645 Mustarde JC, et al, eds. Symposium on Plastic Surgery in the Orbital 33. Adams BJS, Feurstein SS. Complications of blepharoplasty. Ear Nose Region. St Louis: CV Mosby; 1976 Throat J 1986;65(1):11–28 4. Doxanas MT. Blepharoplasty: key anatomical concepts. Facial Plast 34. Castanares S. Complications in blepharoplasty. Clin Plast Surg Surg 1984;1:259 1978;5:149 5. Nesi F, Lisman R, Levine M. Smith’s Ophthalmic Plastic and Reconstruc- 35. Moser MH, DiPirro E, MaCoy FJ. Sudden blindness following blepharo- tive Surgery. 2nd ed. St. Louis: CV Mosby; 1998:1–78 plasty: report of seven cases. Plast Reconstr Surg 1973;51:363 6. Rees TD, Jelks GW. Blepharoplasty and the dry eye syndrome: guide- 36. Anderson RL, Edwards JJ. Bilateral visual loss after blepharoplasty. lines for surgery? Plast Reconstr Surg 1981;68:249 Ann Plast Surg 1980;5:288 7. Jelks GW, McCord CD. Dry eye syndrome and other tear film abnor- 37. Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin malities. Clin Plast Surg 1981;8:803 Plast Surg 1981;8:757 Author Query

Q1: AU: Mosquito clips? unclear. Q2: AU: Ref 28: unpublished material can not be listed in the references. It must be cited in text in parens, such as: (Robin- son L, Crumley RL, unpublished data, 1990). Please move citation to text. Can you provide a substitute reference for Ref 28? If no, delete ref number from text and list and re-number going forward in text and in ref list.